Wheeler, Loren c 4 ?gs
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
tis
,A,' Loren Arthur Wheeler Male
Date of Death Age If Veteran of U.S.Armed Forces,
April 14, 2015 58 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
ill
Circumstances Investigation
,LAT Medical Certifier Name Title
Paul Bachman, M.D.
Address
3767 Main Street Warrensburg, NY 12885
AZ Death Certificate Filed District Number Registeriqun}tter
a` City, Town or Village 5601 qq' 0.
❑Burial Date Cemetery or Crematory
April 14, 201.- Pine View Crematorium
Y 0 Entombment Address
®Cremation Quaker Road Queen. 'iry,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
pi-'_ Hold
n
Date I Point of
ti❑Transportation _ I Shipment
„; by Common Destination
Carrier
f» ❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
J
' Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
71 Address
i, Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
:E1 Remains are Shipped, If Other than Above
17" Address
Permission is hereby granted to dispose of the human re ins des ribed ab ;
've as indi ated.
Date Issued 1 Registrar of Vital Statistics rr a' , 7 7-7) _ i2'`---('
1: g (signature)
'41 District Number 5601 Place 67-enS i4 r/s, /dSe/
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Imo"
00f (section) (lot numbe (grave number)
Name of Sexton or Person in Charge of Premises ��•� /4°''""r
Z please print)
W Signature ��` Title d
(over)
DOH-1555 (02/2004)